The emergency nurse reviews serial findings for clients with acute asthma. Which findings require immediate follow-up? Highlight the findings associated with impending respiratory failure.
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Choose your responses, then check the answer.
Explanation
A silent chest, declining alertness, persistent hypoxemia despite oxygen, and a peak flow of 28% after treatment indicate severe airflow obstruction and possible respiratory failure. Improvement after bronchodilator therapy is less urgent.
Quick answer Escalate immediately for a silent chest despite visible effort, new drowsiness and confusion, oxygen saturation of 88% despite supplemental oxygen, and peak flow at 28% of personal best after repeated treatment.
Why this is correct Severe asthma can progress to hypoxemia, exhaustion, reduced mental alertness, minimal air movement, and respiratory failure. A silent chest is not reassuring when work of breathing remains high; it can mean airflow is too low to produce wheezing.[2]
Easy analogy or mental picture Wheezing is like sound through a narrowed whistle. If the sound disappears while the person is still struggling, almost no air may be crossing the whistle. Quiet plus distress is more dangerous, not calmer.
Memory hook Silent, sleepy, still hypoxic, still below half: escalate.
NCLEX decision rule Judge respiratory status by air movement, oxygenation, mental status, speech, effort, and response to treatment together. Do not use the loudness of wheezing as the sole measure of severity.
Why the other choices are wrong Improved speech, decreasing retractions, oxygen saturation recovery, peak flow improvement, and a mild tremor after albuterol need continued monitoring but show a response rather than impending failure.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
NCBI Bookshelf: Respiratory AlterationsNational Library of Medicine